HomeMy WebLinkAbout16161 � �,�_ CITY OF I}IAM4ND BAi�'. �-''
D�PA,RTMENT OF COMMUNITY&DEVELOPMENT 5ERVICES
- 21660 E.Copley Drive Smte 194
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..,.~• BUILDING PE1tMTT APPLICATION �� .- ,�y � �-� FlRMLY
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� ADDRESS �� ` � r��`'�..1� NUMBER '��t` #�C� - C
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� i HER�Y AfF1�i tRg3ER FEN/SSY OF pERJUAY THq7 I Ak EXEMPF FROM THE 1'�N'TRAGiORS Lt � � 4
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W TUHE,PA�R TO tt8 ISSUANCE,At50 PiEpUIRES iH6 APPUCpNT FOR SUCH PERMIT 50 FIIE A SI6NED w
.,2r STATEMENT 7NAT HE OR 8HE IS LICEN5E0 RURSUANT TO THE PflOYI510N5 PP THE GONTpqGTQRS LI•
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TONS LICENBE LAW.�.
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�s[ LICENSED CONTFACTORS DECLARA710N W � � A � � ��
CL I HEREBY AFFIfiM UNDER NENFa,7Y OP PERIUKY THAT I AM LICENSED UNbEfl PROVI910N5 QF CHAp i ER � �
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WOFiKERS'COMPENSATIOR�DECLARATION Q w;�
� 1 HERE Y AFFIRM UN�R pBdA�,1Y OF pEiL'UHY ON60F T71E WLLOWIWG DECLARATIONS: �
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� ! IHAVEpNOWILLMpJNTNNAC@flTIFfQATEQfCANSENTTOSElWNSVfiEFORWORKERS' 4 •`
CdAPEN5A7qN,A5 PaOlIDE�BY SEC710N SToo OF THE LABOR Go�E.FORTFIF PERwftl.�qrycE U �7^�(\
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� SU9JECT TO THE WpA1{�qg�(x1ldA6N5AT1;)N PROVISiLNS OF SECTIpN 370tl Oh 1 Hk LAtlUN �� �� � �
CA06.i SHALL WpiHWITHGOMPIY WITHTNOS�PqOVI3fONS lSSl.{Ald{`.�
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�j„ SUBIECTANEMPC6YERT4CRIAAIMALPENAI.TIESJdJOCENtFlPtESUPTOONENUNDRGDTNpUSANp �NERGYPERMIT �
Yy„ �OL.LARS(f100.o0ti�.INACIDITIONTOTHECO&TOfGpMP�MSATION,DAMAGE$ASPROVIDEpFORM y �
� s�crpra sToe or�+E e.aeon�aF,iNrEa�st,r.�o nrsoer�rs�Es R�'CENTSON FEE: ������ �
OCONSTRUCTION LENpING AGENCY PRE�AIT�EE: �
� IHEqEBVARFIRMIpJDERVENA�,tYtlFPERJURYTNAT7HEREISACONSTRUCT�ONLENDINGAGENCY
F4R TYfE PERWt#AAriCE OF iHE WORK FOft WtiiCH THIS P�pM171S�SSUED{SEC 30D7,CIV C} 1
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� s�a.��„�E None (Pulte Home Co��
i— LENpER'SAbORESS
QICERTIFV7NATIHAVEREADTHISAPVUCATI6NANp5TA7ETHATTNEAk30VEMFORMA710NISCORflECT TOTAL FEES ��� � � ���1 �'�+��,1 _�
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JOBSITE to csr)C. (E-SS1 016,,,,) bit,ADDRESS
APN LOT_2..&4 TRACT
OWNER k-e,,, cw-e..-.5 54--e,-2.Oo
ADDRESS gat tiovN Af., 1
crrY_.:_--,1%)t n2-, ZIP fi/- bl LT 1 1- 1--
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APPLICANT TEL
CONTRACTO ADDRESS
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ARCH/ENG/DESIGNER ADDRESS CITY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION 54r-piite_ PiNn (4-(a
j PERMIT 1 1 I APPLICATION
DATE NUMBER t.(1. La
TYCOPNEST. P/C atict
ISSUE
DATE OCC GROUP
ZONING
SETBACKS
FRONT REAR
SIDE/SIDE STREET
SIDE
RW
RW
PROPOSED USE
N0. N0.
STORIES BEDROOMS
PRESS FIRMLY
N0. DWEL.
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OWNER-BUILDER DECLARATION
I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI. CENSE LAW FOR THE
FOLLOWII8G REASON(sEc. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMITTO
CONSTRUCT.ALTER IMPROVE, DEMOLISH,OR REPAIR ANY STRUCTURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE
APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS
OF THE CONTRACTORS LI. CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND
PROFESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFFIOM AND THE BASIS FOR THE ALLEGED EXEMPTION.ANY
VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT
MORE THAN FIVE HUNDRED DOLLARS($500).):
L AS OWNER OF THE PROPERTY,OR my EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,WILL DO THE WORK,AND
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSINESS AND PROFESSIONS coDE:THE CONTRACTORS
LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON. SAID WHO DOES SUCH
WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT
INTENDED OR OFFERED FOR SALE It HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD W(THIN ONE YEAR OF COMPLETION,
THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE
OF SALE).
0 I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE
PROJECT(SEC, 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI.CENSE LAW DOES NOT APPLY TO AN OWNER
OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)
LICENSED PURSUANT TO THE CONTRACTORS UCENSE LAW.).
0 I AM EXEMPT UNDER SEC B&P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
II (COMMENCING Inal-t SECTlON 7000)OF DIvisioN 3 OF THE BUSINESS AND PROFESSIONS CODE.AND MY UCENSE IS IN FULL
FORCE AND EFFECT,
LICENSE CLASS A LIC NO 517593
DATE 913/O1 CONTRACTOR Pulte Homes
WORKERS'COMPENSATION DECLARATION
HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'COMPENSATION.As PROVIDED BY
SECTION 3700 oF THE LABOR CODE, FOR THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE,
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE
CARRIER AND POLICY NUMBER ARE:
CARRIER Pacific Employee Ins.co.
POLICY NUTABER WLRC 4307187A
gmts SECTION NEEETFA3TITE OOMPLECED OFTHE PERMIT iS FOR CNE HUNDRED =LARS(tiMoR LESS,.
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF I HE LABOR CODE,I SHALL FORTHWITH
COMPLY WITH THOSE PROVISIONS
DATE: 5/1/O1 APPLICANT: Pulte Homes
WARNING; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE SUBJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,0001.IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
CONSTRUCTlON LENDING AGENCY
/HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097.CIV C)
LENDER'S NAME None(Pulte Home Corp)
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION is CORRECT I AGREE TO COMPLY
WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTlON,AND HEREBY
AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPE TION
PURPOSES.
DESCRIPTION SQ. Fr. iF CTOR PSF ADJ.AREANALUAT ON
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CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE
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VALIDATION R;FII BY
PERMITTEE NAME(PRINT)
SIGN OF PERMITTEE
DATE
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
CITY OF DIAMOND BAR INSPECTION RECORD
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DEV. FEES PAID
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